Patricia L. Kirk

GRAPEVINE, TEX. — The presence of anemia in older adults often signals a serious illness such as cancer, infection, or chronic inflammatory disease, but in diabetics, anemia may be an indication of chronic kidney disease, Dr. Naushira Pandya said at the annual meeting of the American College of Osteopathic Family Physicians.

This link in diabetics between anemia and chronic kidney disease (CKD) arises because, as diabetes progresses, the kidneys become damaged and there is a decrease in the production of erythropoietin, which can also cause anemia, said Dr. Pandya.

He recommended routinely checking diabetics for anemia and noted that the severity of anemia correlates with the severity of underlying disease, which often exists along with other causes of anemia, particularly iron deficiency.

In stressing the importance of checking high-risk patients, Dr. Pandya cited the findings in a study of Medicare patients, which suggested that anemia is a mortality multiplier when combined with another disease.

Anemia of CKD is now also considered a nontraditional risk factor for cardiovascular disease. Erythropoietin deficiency and the resulting reduction in the concentration of hemoglobin causes tissue hypoxia and increased cardiac work, which results in left ventricular hypertrophy and ischemic heart disease.

That, in turn, increases the risk for heart failure, angina pectoris, heart attack, and poor health-related outcomes, explained Dr. Pandya, chair of the department of geriatrics at Nova Southeastern University's College of Osteopathic Medicine in Fort Lauderdale, Fla.

Study findings indicate that anemia doubles the risk for hospitalization for a comorbid condition and significantly increases the risk of premature death in older adults with diabetes, CKD, and heart failure, as well as the risk of stroke in patients with CKD, he noted.

Anemia of CKD is defined by a hemoglobin level of less than 12 g/dL in men and postmenopausal women, and a glomerular filtration rate of 60 mL/min per 1.73 m

Dr. Pandya said that anemic adults experience a decline in functioning because of lower exercise tolerance, muscle wasting, decreased mobility and cardiovascular fitness, greater physical instability and frailty, and an increase in the number of falls. CKD patients, however, have even lower functioning scores than do patients with other comorbid conditions. For example, CKD patients have a mean physical functioning score of 41.2 (0 denotes total disability and 100 denotes full functioning), compared with a mean score of 47.5 in heart failure patients, 67.7 in diabetics without CKD, and 73.4 in hypertensives.

Anemia is effectively a diagnosis of exclusions, because its signs and symptoms, such as weight loss, erectile dysfunction, and often feeling cold, are nonspecific, said Dr. Pandya.

The National Kidney Foundation advises assessing for anemia when the glomerular filtration rate is less than 60 mL/min per 1.73 m

A more extensive work-up, dictated by clinical and laboratory circumstances, and which may include bone marrow aspiration or biopsy, may be needed to determine the cause of anemia.

Dr. Pandya emphasized that it is imperative to identify the cause, because cause directs therapy.

ACD is treated with erythropoietic stimulatory proteins, which are peptide hormones and their derivatives, manufactured by recombinant DNA technology.

The two major products are epoetin alfa (Eprex, Ortho Biologics) and darbepoetin alfa (Aranesp, Amgen Inc.). Darbepoetin's half-life is three times longer than epoetin's half-life. Epoetin alfa is given subcutaneously or intravenously one to three times weekly, whereas 0.45 mcg/kg, given once every 2 weeks, usually maintains a target hemoglobin level of 11–12 g/dL.

GRAPEVINE, TEX. — The presence of anemia in older adults often signals a serious illness such as cancer, infection, or chronic inflammatory disease, but in diabetics, anemia may be an indication of chronic kidney disease, Dr. Naushira Pandya said at the annual meeting of the American College of Osteopathic Family Physicians.

This link in diabetics between anemia and chronic kidney disease (CKD) arises because, as diabetes progresses, the kidneys become damaged and there is a decrease in the production of erythropoietin, which can also cause anemia, said Dr. Pandya.

He recommended routinely checking diabetics for anemia and noted that the severity of anemia correlates with the severity of underlying disease, which often exists along with other causes of anemia, particularly iron deficiency.

In stressing the importance of checking high-risk patients, Dr. Pandya cited the findings in a study of Medicare patients, which suggested that anemia is a mortality multiplier when combined with another disease.

Anemia of CKD is now also considered a nontraditional risk factor for cardiovascular disease. Erythropoietin deficiency and the resulting reduction in the concentration of hemoglobin causes tissue hypoxia and increased cardiac work, which results in left ventricular hypertrophy and ischemic heart disease.

That, in turn, increases the risk for heart failure, angina pectoris, heart attack, and poor health-related outcomes, explained Dr. Pandya, chair of the department of geriatrics at Nova Southeastern University's College of Osteopathic Medicine in Fort Lauderdale, Fla.

Study findings indicate that anemia doubles the risk for hospitalization for a comorbid condition and significantly increases the risk of premature death in older adults with diabetes, CKD, and heart failure, as well as the risk of stroke in patients with CKD, he noted.

Anemia of CKD is defined by a hemoglobin level of less than 12 g/dL in men and postmenopausal women, and a glomerular filtration rate of 60 mL/min per 1.73 m

Dr. Pandya said that anemic adults experience a decline in functioning because of lower exercise tolerance, muscle wasting, decreased mobility and cardiovascular fitness, greater physical instability and frailty, and an increase in the number of falls. CKD patients, however, have even lower functioning scores than do patients with other comorbid conditions. For example, CKD patients have a mean physical functioning score of 41.2 (0 denotes total disability and 100 denotes full functioning), compared with a mean score of 47.5 in heart failure patients, 67.7 in diabetics without CKD, and 73.4 in hypertensives.

Anemia is effectively a diagnosis of exclusions, because its signs and symptoms, such as weight loss, erectile dysfunction, and often feeling cold, are nonspecific, said Dr. Pandya.

The National Kidney Foundation advises assessing for anemia when the glomerular filtration rate is less than 60 mL/min per 1.73 m

A more extensive work-up, dictated by clinical and laboratory circumstances, and which may include bone marrow aspiration or biopsy, may be needed to determine the cause of anemia.

Dr. Pandya emphasized that it is imperative to identify the cause, because cause directs therapy.

ACD is treated with erythropoietic stimulatory proteins, which are peptide hormones and their derivatives, manufactured by recombinant DNA technology.

The two major products are epoetin alfa (Eprex, Ortho Biologics) and darbepoetin alfa (Aranesp, Amgen Inc.). Darbepoetin's half-life is three times longer than epoetin's half-life. Epoetin alfa is given subcutaneously or intravenously one to three times weekly, whereas 0.45 mcg/kg, given once every 2 weeks, usually maintains a target hemoglobin level of 11–12 g/dL.

GRAPEVINE, TEX. — The presence of anemia in older adults often signals a serious illness such as cancer, infection, or chronic inflammatory disease, but in diabetics, anemia may be an indication of chronic kidney disease, Dr. Naushira Pandya said at the annual meeting of the American College of Osteopathic Family Physicians.

This link in diabetics between anemia and chronic kidney disease (CKD) arises because, as diabetes progresses, the kidneys become damaged and there is a decrease in the production of erythropoietin, which can also cause anemia, said Dr. Pandya.

He recommended routinely checking diabetics for anemia and noted that the severity of anemia correlates with the severity of underlying disease, which often exists along with other causes of anemia, particularly iron deficiency.

In stressing the importance of checking high-risk patients, Dr. Pandya cited the findings in a study of Medicare patients, which suggested that anemia is a mortality multiplier when combined with another disease.

Anemia of CKD is now also considered a nontraditional risk factor for cardiovascular disease. Erythropoietin deficiency and the resulting reduction in the concentration of hemoglobin causes tissue hypoxia and increased cardiac work, which results in left ventricular hypertrophy and ischemic heart disease.

That, in turn, increases the risk for heart failure, angina pectoris, heart attack, and poor health-related outcomes, explained Dr. Pandya, chair of the department of geriatrics at Nova Southeastern University's College of Osteopathic Medicine in Fort Lauderdale, Fla.

Study findings indicate that anemia doubles the risk for hospitalization for a comorbid condition and significantly increases the risk of premature death in older adults with diabetes, CKD, and heart failure, as well as the risk of stroke in patients with CKD, he noted.

Anemia of CKD is defined by a hemoglobin level of less than 12 g/dL in men and postmenopausal women, and a glomerular filtration rate of 60 mL/min per 1.73 m

Dr. Pandya said that anemic adults experience a decline in functioning because of lower exercise tolerance, muscle wasting, decreased mobility and cardiovascular fitness, greater physical instability and frailty, and an increase in the number of falls. CKD patients, however, have even lower functioning scores than do patients with other comorbid conditions. For example, CKD patients have a mean physical functioning score of 41.2 (0 denotes total disability and 100 denotes full functioning), compared with a mean score of 47.5 in heart failure patients, 67.7 in diabetics without CKD, and 73.4 in hypertensives.

Anemia is effectively a diagnosis of exclusions, because its signs and symptoms, such as weight loss, erectile dysfunction, and often feeling cold, are nonspecific, said Dr. Pandya.

The National Kidney Foundation advises assessing for anemia when the glomerular filtration rate is less than 60 mL/min per 1.73 m

A more extensive work-up, dictated by clinical and laboratory circumstances, and which may include bone marrow aspiration or biopsy, may be needed to determine the cause of anemia.

Dr. Pandya emphasized that it is imperative to identify the cause, because cause directs therapy.

ACD is treated with erythropoietic stimulatory proteins, which are peptide hormones and their derivatives, manufactured by recombinant DNA technology.

The two major products are epoetin alfa (Eprex, Ortho Biologics) and darbepoetin alfa (Aranesp, Amgen Inc.). Darbepoetin's half-life is three times longer than epoetin's half-life. Epoetin alfa is given subcutaneously or intravenously one to three times weekly, whereas 0.45 mcg/kg, given once every 2 weeks, usually maintains a target hemoglobin level of 11–12 g/dL.

GRAPEVINE, TEX. — A combination of fibrates and statins to target different lipids may provide the best protection against cardiovascular events in diabetics and patients with metabolic syndrome, said Dr. Alistair I. Fyfe at the annual convention of the American College of Osteopathic Family Physicians.

The incidence of metabolic syndrome and type 2 diabetes is increasing because of the “fattening of America,” he said, noting that on average, Americans have gained 30 pounds since 1985.

Metabolic syndrome is a research term that refers to a combination of related health factors that together increase the risk for heart disease, including insulin resistance, obesity, unhealthy lipid levels, high blood pressure, and signs of kidney disease.

A hallmark of metabolic syndrome is the accumulation of visceral adipose fat, leading to disturbances in various cardiometabolic risk factors, which can increase insulin resistance and risk for both type 2 diabetes and heart attack.

The rationale for a combination treatment has evolved from a number of clinical trials that evaluated the efficacy of statins and fibrates in reducing cardiometabolic risk factors alone and together, said Dr. Fyfe, director of primary and secondary cardiac prevention at Medical City Hospital in Dallas.

“More patients achieve American Diabetes Association goals with combined drug therapy,” he said.

Diabetic subanalyses of four major placebo-controlled clinical trials that evaluated the efficacy of statins, a class of lipid-lowering drugs, to treat hypercholesterolemia, concluded that statins alone do not reduce cardiovascular risk in diabetic patients, said Dr. Fyfe. Cardiac risk in diabetics and people with metabolic syndrome is associated with elevated triglycerides and low HDL cholesterol, he explained.

Statins cured hypercholesterolemia in about one-third of study participants, but had no effect on the other 70%, he said. “Diabetic patients need to be treated differently [than other high-risk patients]. There is no doubt that statin therapy is here to stay; it is the right drug for 30% of people.”

Niacin and fibrates, another class of lipid-lowering drugs, improve triglycerides and increase HDL cholesterol. However, niacin is contraindicated for diabetics because it worsens insulin resistance. Fibrates have been used clinically since the 1970s to treat unhealthy lipids, but their mechanism of action was unclear until the 1990s, when researchers discovered that they activate peroxisome proliferator-activated receptors, which modulate carbohydrate and fat metabolism and adipose tissue differentiation.

By lowering triglycerides and raising HDL cholesterol levels, fibrates decrease the concentration of very-low-density lipoprotein (VLDL), resulting in a lower concentration of LDL cholesterol particles and increased particle size, which makes it easier for them to be eliminated from blood compared with small particles, Dr. Fyfe said, adding that elevated triglycerides are the result of an increase in VLDL.

Statins reduce hepatic cholesterol synthesis, which lowers intracellular cholesterol, which in turn stimulates upregulation of LDL cholesterol receptors and increases the uptake of non-HDL cholesterol particles from the blood. With the combined therapy, “the fibrate makes LDL available for the statin to clean out of the blood,” he said.

The results of several studies have verified the efficacy of combined therapy in diabetics. In one study, 120 patients were given 20 mg of atorvastatin or 200 mg of fenofibrate alone or a combination of the two drugs (Diabetes Care 2002;25:1198–202). The researchers recorded a 46% drop in LDL, a 50% reduction in triglycerides, and a 22% increase in HDL for participants who were given the combination therapy, compared with a 40% decline in LDL, a 30% drop in triglycerides, and a 9% increase in HDL for those who were given atorvastatin alone and a 15% decline in LDL, 41% reduction in triglycerides, and 15% increase in HDL in those who were given fenofibrate alone.

In another study, involving 618 participants, a combination of 20 mg of simvastatin and 160 mg of fenofibrate lowered LDL by 31%, VLDL by 48%, and triglycerides by 43% and raised HDL by 19%, compared with reductions of 26% in LDL, 24% in VLDL, and 20% in triglycerides and an increase of 10% in HDL in those who received 20 mg of simvastatin alone (Am. J. Cardiol. 2005;95:462–8).

GRAPEVINE, TEX. — A combination of fibrates and statins to target different lipids may provide the best protection against cardiovascular events in diabetics and patients with metabolic syndrome, said Dr. Alistair I. Fyfe at the annual convention of the American College of Osteopathic Family Physicians.

The incidence of metabolic syndrome and type 2 diabetes is increasing because of the “fattening of America,” he said, noting that on average, Americans have gained 30 pounds since 1985.

Metabolic syndrome is a research term that refers to a combination of related health factors that together increase the risk for heart disease, including insulin resistance, obesity, unhealthy lipid levels, high blood pressure, and signs of kidney disease.

A hallmark of metabolic syndrome is the accumulation of visceral adipose fat, leading to disturbances in various cardiometabolic risk factors, which can increase insulin resistance and risk for both type 2 diabetes and heart attack.

The rationale for a combination treatment has evolved from a number of clinical trials that evaluated the efficacy of statins and fibrates in reducing cardiometabolic risk factors alone and together, said Dr. Fyfe, director of primary and secondary cardiac prevention at Medical City Hospital in Dallas.

“More patients achieve American Diabetes Association goals with combined drug therapy,” he said.

Diabetic subanalyses of four major placebo-controlled clinical trials that evaluated the efficacy of statins, a class of lipid-lowering drugs, to treat hypercholesterolemia, concluded that statins alone do not reduce cardiovascular risk in diabetic patients, said Dr. Fyfe. Cardiac risk in diabetics and people with metabolic syndrome is associated with elevated triglycerides and low HDL cholesterol, he explained.

Statins cured hypercholesterolemia in about one-third of study participants, but had no effect on the other 70%, he said. “Diabetic patients need to be treated differently [than other high-risk patients]. There is no doubt that statin therapy is here to stay; it is the right drug for 30% of people.”

Niacin and fibrates, another class of lipid-lowering drugs, improve triglycerides and increase HDL cholesterol. However, niacin is contraindicated for diabetics because it worsens insulin resistance. Fibrates have been used clinically since the 1970s to treat unhealthy lipids, but their mechanism of action was unclear until the 1990s, when researchers discovered that they activate peroxisome proliferator-activated receptors, which modulate carbohydrate and fat metabolism and adipose tissue differentiation.

By lowering triglycerides and raising HDL cholesterol levels, fibrates decrease the concentration of very-low-density lipoprotein (VLDL), resulting in a lower concentration of LDL cholesterol particles and increased particle size, which makes it easier for them to be eliminated from blood compared with small particles, Dr. Fyfe said, adding that elevated triglycerides are the result of an increase in VLDL.

Statins reduce hepatic cholesterol synthesis, which lowers intracellular cholesterol, which in turn stimulates upregulation of LDL cholesterol receptors and increases the uptake of non-HDL cholesterol particles from the blood. With the combined therapy, “the fibrate makes LDL available for the statin to clean out of the blood,” he said.

The results of several studies have verified the efficacy of combined therapy in diabetics. In one study, 120 patients were given 20 mg of atorvastatin or 200 mg of fenofibrate alone or a combination of the two drugs (Diabetes Care 2002;25:1198–202). The researchers recorded a 46% drop in LDL, a 50% reduction in triglycerides, and a 22% increase in HDL for participants who were given the combination therapy, compared with a 40% decline in LDL, a 30% drop in triglycerides, and a 9% increase in HDL for those who were given atorvastatin alone and a 15% decline in LDL, 41% reduction in triglycerides, and 15% increase in HDL in those who were given fenofibrate alone.

In another study, involving 618 participants, a combination of 20 mg of simvastatin and 160 mg of fenofibrate lowered LDL by 31%, VLDL by 48%, and triglycerides by 43% and raised HDL by 19%, compared with reductions of 26% in LDL, 24% in VLDL, and 20% in triglycerides and an increase of 10% in HDL in those who received 20 mg of simvastatin alone (Am. J. Cardiol. 2005;95:462–8).

GRAPEVINE, TEX. — A combination of fibrates and statins to target different lipids may provide the best protection against cardiovascular events in diabetics and patients with metabolic syndrome, said Dr. Alistair I. Fyfe at the annual convention of the American College of Osteopathic Family Physicians.

The incidence of metabolic syndrome and type 2 diabetes is increasing because of the “fattening of America,” he said, noting that on average, Americans have gained 30 pounds since 1985.

Metabolic syndrome is a research term that refers to a combination of related health factors that together increase the risk for heart disease, including insulin resistance, obesity, unhealthy lipid levels, high blood pressure, and signs of kidney disease.

A hallmark of metabolic syndrome is the accumulation of visceral adipose fat, leading to disturbances in various cardiometabolic risk factors, which can increase insulin resistance and risk for both type 2 diabetes and heart attack.

The rationale for a combination treatment has evolved from a number of clinical trials that evaluated the efficacy of statins and fibrates in reducing cardiometabolic risk factors alone and together, said Dr. Fyfe, director of primary and secondary cardiac prevention at Medical City Hospital in Dallas.

“More patients achieve American Diabetes Association goals with combined drug therapy,” he said.

Diabetic subanalyses of four major placebo-controlled clinical trials that evaluated the efficacy of statins, a class of lipid-lowering drugs, to treat hypercholesterolemia, concluded that statins alone do not reduce cardiovascular risk in diabetic patients, said Dr. Fyfe. Cardiac risk in diabetics and people with metabolic syndrome is associated with elevated triglycerides and low HDL cholesterol, he explained.

Statins cured hypercholesterolemia in about one-third of study participants, but had no effect on the other 70%, he said. “Diabetic patients need to be treated differently [than other high-risk patients]. There is no doubt that statin therapy is here to stay; it is the right drug for 30% of people.”

Niacin and fibrates, another class of lipid-lowering drugs, improve triglycerides and increase HDL cholesterol. However, niacin is contraindicated for diabetics because it worsens insulin resistance. Fibrates have been used clinically since the 1970s to treat unhealthy lipids, but their mechanism of action was unclear until the 1990s, when researchers discovered that they activate peroxisome proliferator-activated receptors, which modulate carbohydrate and fat metabolism and adipose tissue differentiation.

By lowering triglycerides and raising HDL cholesterol levels, fibrates decrease the concentration of very-low-density lipoprotein (VLDL), resulting in a lower concentration of LDL cholesterol particles and increased particle size, which makes it easier for them to be eliminated from blood compared with small particles, Dr. Fyfe said, adding that elevated triglycerides are the result of an increase in VLDL.

Statins reduce hepatic cholesterol synthesis, which lowers intracellular cholesterol, which in turn stimulates upregulation of LDL cholesterol receptors and increases the uptake of non-HDL cholesterol particles from the blood. With the combined therapy, “the fibrate makes LDL available for the statin to clean out of the blood,” he said.

The results of several studies have verified the efficacy of combined therapy in diabetics. In one study, 120 patients were given 20 mg of atorvastatin or 200 mg of fenofibrate alone or a combination of the two drugs (Diabetes Care 2002;25:1198–202). The researchers recorded a 46% drop in LDL, a 50% reduction in triglycerides, and a 22% increase in HDL for participants who were given the combination therapy, compared with a 40% decline in LDL, a 30% drop in triglycerides, and a 9% increase in HDL for those who were given atorvastatin alone and a 15% decline in LDL, 41% reduction in triglycerides, and 15% increase in HDL in those who were given fenofibrate alone.

In another study, involving 618 participants, a combination of 20 mg of simvastatin and 160 mg of fenofibrate lowered LDL by 31%, VLDL by 48%, and triglycerides by 43% and raised HDL by 19%, compared with reductions of 26% in LDL, 24% in VLDL, and 20% in triglycerides and an increase of 10% in HDL in those who received 20 mg of simvastatin alone (Am. J. Cardiol. 2005;95:462–8).

DALLAS — More patients are presenting with complications resulting from poor eating patterns and failure to take required nutritional supplements after bariatric surgery, Margaret Malone, Ph.D., said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Most complications can be prevented by teaching patients how to adapt food and fluid intake to a stomach pouch with capacity limited to 15–30 mL and educating them about the need for lifelong supplements, stressed Dr. Malone, a professor at Albany (New York) College of Pharmacy.

According to a recent study, 10% of bariatric surgery patients require rehospitalization because of the inability to keep up with fluid requirements (Obesity Res. 2005;13:2202–9). Dr. Malone stressed the need to instruct patients to sip water all day, avoid large gulps, and separate liquids from solids at mealtime.

A major problem in managing these patients is that nutritional monitoring frequently stops after the first year, once the weight-loss goal has been achieved. To ensure adequate protein intake, Dr. Malone suggested that patients eat protein first, before becoming full, and/or use protein supplements. Vitamin B₁₂, folate, and iron are commonly deficient in gastric bypass patients. Dr. Malone said she recommends 60 mg iron, 2–3 times daily. She stressed the need to monitor menstruating women for anemia, noting that many of them require IV iron replacement several times a year.

Alterations in medications routinely taken by patients may also be required after gastric bypass. Hydrophilic, or water soluble, drugs that are distributed into lean body mass should be dosed according to ideal body weight, she said, while dosage for lipophilic, or fat soluble, drugs, which are distributed equally between lean and fat body mass, should be calculated according to actual body weight. Drug dosages aimed at achieving a defined therapeutic outcome, such as blood pressure and blood glucose level, should be titrated upward until the goal is met, similar to what is done in normal-weight patients.

Dr. Malone recommended avoiding slow-release supplements, especially iron, as well as drugs that require acidic pH for absorption, such as ampicillin; drugs known for poor absorption in normal people, such as protease inhibitors; or drugs that cause gastric ulceration/irritation, such as NSAIDS, aspirin, and potassium. She also suggested selecting chewable or soluble calcium products, such as Citracal liquitabs, rather than large pills or tablets.

Gastric bypass patients also frequently report greater sensitivity to alcohol intake, Dr. Malone said, emphasizing the need to counsel patients on eliminating or limiting alcohol consumption, especially during the first year postop.

DALLAS — More patients are presenting with complications resulting from poor eating patterns and failure to take required nutritional supplements after bariatric surgery, Margaret Malone, Ph.D., said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Most complications can be prevented by teaching patients how to adapt food and fluid intake to a stomach pouch with capacity limited to 15–30 mL and educating them about the need for lifelong supplements, stressed Dr. Malone, a professor at Albany (New York) College of Pharmacy.

According to a recent study, 10% of bariatric surgery patients require rehospitalization because of the inability to keep up with fluid requirements (Obesity Res. 2005;13:2202–9). Dr. Malone stressed the need to instruct patients to sip water all day, avoid large gulps, and separate liquids from solids at mealtime.

A major problem in managing these patients is that nutritional monitoring frequently stops after the first year, once the weight-loss goal has been achieved. To ensure adequate protein intake, Dr. Malone suggested that patients eat protein first, before becoming full, and/or use protein supplements. Vitamin B₁₂, folate, and iron are commonly deficient in gastric bypass patients. Dr. Malone said she recommends 60 mg iron, 2–3 times daily. She stressed the need to monitor menstruating women for anemia, noting that many of them require IV iron replacement several times a year.

Alterations in medications routinely taken by patients may also be required after gastric bypass. Hydrophilic, or water soluble, drugs that are distributed into lean body mass should be dosed according to ideal body weight, she said, while dosage for lipophilic, or fat soluble, drugs, which are distributed equally between lean and fat body mass, should be calculated according to actual body weight. Drug dosages aimed at achieving a defined therapeutic outcome, such as blood pressure and blood glucose level, should be titrated upward until the goal is met, similar to what is done in normal-weight patients.

Dr. Malone recommended avoiding slow-release supplements, especially iron, as well as drugs that require acidic pH for absorption, such as ampicillin; drugs known for poor absorption in normal people, such as protease inhibitors; or drugs that cause gastric ulceration/irritation, such as NSAIDS, aspirin, and potassium. She also suggested selecting chewable or soluble calcium products, such as Citracal liquitabs, rather than large pills or tablets.

Gastric bypass patients also frequently report greater sensitivity to alcohol intake, Dr. Malone said, emphasizing the need to counsel patients on eliminating or limiting alcohol consumption, especially during the first year postop.

DALLAS — More patients are presenting with complications resulting from poor eating patterns and failure to take required nutritional supplements after bariatric surgery, Margaret Malone, Ph.D., said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Most complications can be prevented by teaching patients how to adapt food and fluid intake to a stomach pouch with capacity limited to 15–30 mL and educating them about the need for lifelong supplements, stressed Dr. Malone, a professor at Albany (New York) College of Pharmacy.

According to a recent study, 10% of bariatric surgery patients require rehospitalization because of the inability to keep up with fluid requirements (Obesity Res. 2005;13:2202–9). Dr. Malone stressed the need to instruct patients to sip water all day, avoid large gulps, and separate liquids from solids at mealtime.

A major problem in managing these patients is that nutritional monitoring frequently stops after the first year, once the weight-loss goal has been achieved. To ensure adequate protein intake, Dr. Malone suggested that patients eat protein first, before becoming full, and/or use protein supplements. Vitamin B₁₂, folate, and iron are commonly deficient in gastric bypass patients. Dr. Malone said she recommends 60 mg iron, 2–3 times daily. She stressed the need to monitor menstruating women for anemia, noting that many of them require IV iron replacement several times a year.

Alterations in medications routinely taken by patients may also be required after gastric bypass. Hydrophilic, or water soluble, drugs that are distributed into lean body mass should be dosed according to ideal body weight, she said, while dosage for lipophilic, or fat soluble, drugs, which are distributed equally between lean and fat body mass, should be calculated according to actual body weight. Drug dosages aimed at achieving a defined therapeutic outcome, such as blood pressure and blood glucose level, should be titrated upward until the goal is met, similar to what is done in normal-weight patients.

Dr. Malone recommended avoiding slow-release supplements, especially iron, as well as drugs that require acidic pH for absorption, such as ampicillin; drugs known for poor absorption in normal people, such as protease inhibitors; or drugs that cause gastric ulceration/irritation, such as NSAIDS, aspirin, and potassium. She also suggested selecting chewable or soluble calcium products, such as Citracal liquitabs, rather than large pills or tablets.

Gastric bypass patients also frequently report greater sensitivity to alcohol intake, Dr. Malone said, emphasizing the need to counsel patients on eliminating or limiting alcohol consumption, especially during the first year postop.

GRAPEVINE, TEX. — At least 6% of patients diagnosed with dementia are actually suffering from normal-pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal-pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalography, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of neurology and neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function. The sphere of distended ventricles grows larger over time, causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, and have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks—all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said. The urologic symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on CT or MRI; a gradual progressive course of symptoms; and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid. Gait tests should be performed before and after a lumbar drain of 50–100 cc per day for 3 days in hard-to-diagnose cases to see if the patient improves, he says, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working. One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline. Patients who perform better following a simple tap test are most likely to improve following this strategy.

Ten percent of patients undergoing this procedure have complications, but those complications are generally are not serious. Mortality due to hydrocephalus is unknown. “But with early detection there is definitely a better chance for a good outcome,” he said.

GRAPEVINE, TEX. — At least 6% of patients diagnosed with dementia are actually suffering from normal-pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal-pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalography, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of neurology and neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function. The sphere of distended ventricles grows larger over time, causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, and have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks—all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said. The urologic symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on CT or MRI; a gradual progressive course of symptoms; and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid. Gait tests should be performed before and after a lumbar drain of 50–100 cc per day for 3 days in hard-to-diagnose cases to see if the patient improves, he says, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working. One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline. Patients who perform better following a simple tap test are most likely to improve following this strategy.

Ten percent of patients undergoing this procedure have complications, but those complications are generally are not serious. Mortality due to hydrocephalus is unknown. “But with early detection there is definitely a better chance for a good outcome,” he said.

GRAPEVINE, TEX. — At least 6% of patients diagnosed with dementia are actually suffering from normal-pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal-pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalography, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of neurology and neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function. The sphere of distended ventricles grows larger over time, causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, and have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks—all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said. The urologic symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on CT or MRI; a gradual progressive course of symptoms; and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid. Gait tests should be performed before and after a lumbar drain of 50–100 cc per day for 3 days in hard-to-diagnose cases to see if the patient improves, he says, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working. One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline. Patients who perform better following a simple tap test are most likely to improve following this strategy.

Ten percent of patients undergoing this procedure have complications, but those complications are generally are not serious. Mortality due to hydrocephalus is unknown. “But with early detection there is definitely a better chance for a good outcome,” he said.

GRAPEVINE, TEX. – At least 6% of patients diagnosed with dementia are actually suffering from normal pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalogram, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of Neurology and Neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function.

The sphere of distended ventricles grows larger over time causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks–-all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push up on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said.

The urological symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on either computed tomography (CT) or MRI; a gradual progressive course of symptoms, and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid (CSF).

Gait tests should be performed before and after a lumbar drain of 50–100 cc/day for 3 days in hard-to-diagnose cases to see if the patient improves, he said, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working.

One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline.

Patients who perform better following a simple tap test are most likely to improve following this strategy.

About 10% of patients undergoing this procedure have complications, but those complications generally are not serious. “Nobody knows how many people actually die from normal pressure hydrocephalus,” said Dr. Maxwell. “But with early detection there is definitely a better chance for a good outcome.”

GRAPEVINE, TEX. – At least 6% of patients diagnosed with dementia are actually suffering from normal pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalogram, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of Neurology and Neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function.

The sphere of distended ventricles grows larger over time causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks–-all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push up on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said.

The urological symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on either computed tomography (CT) or MRI; a gradual progressive course of symptoms, and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid (CSF).

Gait tests should be performed before and after a lumbar drain of 50–100 cc/day for 3 days in hard-to-diagnose cases to see if the patient improves, he said, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working.

One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline.

Patients who perform better following a simple tap test are most likely to improve following this strategy.

About 10% of patients undergoing this procedure have complications, but those complications generally are not serious. “Nobody knows how many people actually die from normal pressure hydrocephalus,” said Dr. Maxwell. “But with early detection there is definitely a better chance for a good outcome.”

GRAPEVINE, TEX. – At least 6% of patients diagnosed with dementia are actually suffering from normal pressure hydrocephalus, which often can be treated, Dr. Mark S. Maxwell said at the annual meeting of the American College of Osteopathic Family Physicians.

Normal pressure hydrocephalus (NPH) usually occurs in people with a history of arachnoid insult in which infection or bleeding affects the ability to absorb spinal fluid. And the prevalence of NPH is rising because of improved detection.

However, there are still populations in whom NPH goes unidentified. NPH can be seen on encephalogram, but physicians frequently fail to order this test in elderly patients because cognitive symptoms resemble subcortical dementia, and the symptoms can take years to manifest, explained Dr. Maxwell, chair of Neurology and Neurosurgery at Hendrick Medical Center in Abilene, Tex.

Unlike hydrocephalus in children, which has a rapid onset, NPH in older populations involves a gradual process of ventricular enlargement that takes years to encroach on surrounding tissue and vessels and affect cognitive function.

The sphere of distended ventricles grows larger over time causing a triad of symptoms, including gait unsteadiness, psychomotor retardation, and urinary incontinence, commonly referred to as wet, wobbly, and wacky.

About 80% of NPH patients exhibit cognitive impairment that is characterized by being inattentive and easily sidetracked, and having memory loss and slow but accurate recall. These patients also lack spontaneity, have trouble forming words, interpreting stimuli, and carrying out simple sequential tasks–-all of which may be mistaken for subcortical dementia symptoms.

About 90% of NPH patients are wobbly. These patients have a hard time initiating gait, and often fall down, he said. They also walk slowly, take shorter strides, shuffle their feet, and tend to lean forward and push up on walls or whatever is handy to steady themselves.

After the onset of gait changes, up to 90% of NPH patients develop early symptoms of incontinence, in which there is a sudden sense of urgency to urinate, Dr. Maxwell said.

The urological symptoms stem from poor detrusor contraction. He pointed out that this symptom differs from overflow incontinence in that the need to void is a surprise.

In diagnosing NPH, Dr. Maxwell provided a checklist: history of wet, wobbly, and wacky; enlarged ventricles on either computed tomography (CT) or MRI; a gradual progressive course of symptoms, and a history of falls.

Tests should be performed to rule out Alzheimer's disease and dementia. Testing might involve cisternography with a high-volume tap of 50 cc of cerebrospinal fluid (CSF).

Gait tests should be performed before and after a lumbar drain of 50–100 cc/day for 3 days in hard-to-diagnose cases to see if the patient improves, he said, noting that lumbar drain is the standard test.

In the case of NPH from an excess of fluid, a shunt with a valve is implanted to keep fluid from backing up, said Dr. Maxwell. A needle can be inserted so that spinal samples can be routinely checked to see if the shunt is still working.

One-third of patients undergoing this procedure experience significant improvement, one-third stabilize or experience minor change, and the other third continue to decline.

Patients who perform better following a simple tap test are most likely to improve following this strategy.

About 10% of patients undergoing this procedure have complications, but those complications generally are not serious. “Nobody knows how many people actually die from normal pressure hydrocephalus,” said Dr. Maxwell. “But with early detection there is definitely a better chance for a good outcome.”

DALLAS — Dysphagia is common in children with autistic spectrum disorder, presenting nutritional deficiencies that can affect growth and development and health in general, Dr. Rhonda S. Walter said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Dr. Walter, chief of developmental pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del., noted that improving nutrition in ASD children is challenging because dysphagia presents in various ways, including food selectivity or refusal and disruptive mealtime behavior. It commonly involves GI conditions like reflux, constipation, absorptive function or leaky gut, as well as biobehavior issues such as disordered attention regulation, rigidity, and sensory processing/integration disorder. Constipation is the most common GI complaint, with up to 37% of ASD children presenting with this problem.

“The main question is whether the eating disorder is attributable to autism or concomitant with associated medical disorders,” Dr. Walter said, stressing that improving nutrition in ASD children often requires a multidisciplinary team approach to evaluate the dysphagia and devise a treatment plan that emphasizes a whole child approach to managing GI problems, improving nutrition, and advancing food intake at feedings.

Assessment goals include documenting safety of swallow function, assessing the need for diet/food modification, identifying supplemental nutritional supports, diagnosing GI symptoms contributing to eating problems, and formulating objectives for achieving desired outcomes.

A treatment plan includes managing GI conditions and improving nutritional deficiencies with diet and supplements, as well as devising strategies to help parents overcome mealtime behavior issues.

She explained that autistic children may have an underlying sensory processing disorder that prevents normal organization, integration and use of stimuli from the environment, resulting in over- or underarousal of senses, learning problems, disruptive mealtime behavior, and inadequate food intake.

The inability to organize information may manifest as obsessive/compulsive food aversions, such as white things touching green things, Dr. Walter said. “Many kids are not organized enough to sit in a chair or sit and gaze at their food,” she added, noting that mealtime can take 40–60 minutes.

Treatment aimed at advancing feedings typically involves giving an appetite stimulant such as cyproheptadine or megestrol and desensitizing the child to food offered, noted Dr. Walter. “This is a field that begs to be standardized,” she added.

She stressed that behavioral strategies must correlate with developmental rather than chronologic age and recommended achieving food volume with lower texture form before upgrading to next—applesauce to apple pieces—and introducing new foods with familiar texture level or pairing them with familiar tastes.

DALLAS — Dysphagia is common in children with autistic spectrum disorder, presenting nutritional deficiencies that can affect growth and development and health in general, Dr. Rhonda S. Walter said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Dr. Walter, chief of developmental pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del., noted that improving nutrition in ASD children is challenging because dysphagia presents in various ways, including food selectivity or refusal and disruptive mealtime behavior. It commonly involves GI conditions like reflux, constipation, absorptive function or leaky gut, as well as biobehavior issues such as disordered attention regulation, rigidity, and sensory processing/integration disorder. Constipation is the most common GI complaint, with up to 37% of ASD children presenting with this problem.

“The main question is whether the eating disorder is attributable to autism or concomitant with associated medical disorders,” Dr. Walter said, stressing that improving nutrition in ASD children often requires a multidisciplinary team approach to evaluate the dysphagia and devise a treatment plan that emphasizes a whole child approach to managing GI problems, improving nutrition, and advancing food intake at feedings.

Assessment goals include documenting safety of swallow function, assessing the need for diet/food modification, identifying supplemental nutritional supports, diagnosing GI symptoms contributing to eating problems, and formulating objectives for achieving desired outcomes.

A treatment plan includes managing GI conditions and improving nutritional deficiencies with diet and supplements, as well as devising strategies to help parents overcome mealtime behavior issues.

She explained that autistic children may have an underlying sensory processing disorder that prevents normal organization, integration and use of stimuli from the environment, resulting in over- or underarousal of senses, learning problems, disruptive mealtime behavior, and inadequate food intake.

The inability to organize information may manifest as obsessive/compulsive food aversions, such as white things touching green things, Dr. Walter said. “Many kids are not organized enough to sit in a chair or sit and gaze at their food,” she added, noting that mealtime can take 40–60 minutes.

Treatment aimed at advancing feedings typically involves giving an appetite stimulant such as cyproheptadine or megestrol and desensitizing the child to food offered, noted Dr. Walter. “This is a field that begs to be standardized,” she added.

She stressed that behavioral strategies must correlate with developmental rather than chronologic age and recommended achieving food volume with lower texture form before upgrading to next—applesauce to apple pieces—and introducing new foods with familiar texture level or pairing them with familiar tastes.

DALLAS — Dysphagia is common in children with autistic spectrum disorder, presenting nutritional deficiencies that can affect growth and development and health in general, Dr. Rhonda S. Walter said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Dr. Walter, chief of developmental pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del., noted that improving nutrition in ASD children is challenging because dysphagia presents in various ways, including food selectivity or refusal and disruptive mealtime behavior. It commonly involves GI conditions like reflux, constipation, absorptive function or leaky gut, as well as biobehavior issues such as disordered attention regulation, rigidity, and sensory processing/integration disorder. Constipation is the most common GI complaint, with up to 37% of ASD children presenting with this problem.

“The main question is whether the eating disorder is attributable to autism or concomitant with associated medical disorders,” Dr. Walter said, stressing that improving nutrition in ASD children often requires a multidisciplinary team approach to evaluate the dysphagia and devise a treatment plan that emphasizes a whole child approach to managing GI problems, improving nutrition, and advancing food intake at feedings.

Assessment goals include documenting safety of swallow function, assessing the need for diet/food modification, identifying supplemental nutritional supports, diagnosing GI symptoms contributing to eating problems, and formulating objectives for achieving desired outcomes.

A treatment plan includes managing GI conditions and improving nutritional deficiencies with diet and supplements, as well as devising strategies to help parents overcome mealtime behavior issues.

She explained that autistic children may have an underlying sensory processing disorder that prevents normal organization, integration and use of stimuli from the environment, resulting in over- or underarousal of senses, learning problems, disruptive mealtime behavior, and inadequate food intake.

The inability to organize information may manifest as obsessive/compulsive food aversions, such as white things touching green things, Dr. Walter said. “Many kids are not organized enough to sit in a chair or sit and gaze at their food,” she added, noting that mealtime can take 40–60 minutes.

Treatment aimed at advancing feedings typically involves giving an appetite stimulant such as cyproheptadine or megestrol and desensitizing the child to food offered, noted Dr. Walter. “This is a field that begs to be standardized,” she added.

She stressed that behavioral strategies must correlate with developmental rather than chronologic age and recommended achieving food volume with lower texture form before upgrading to next—applesauce to apple pieces—and introducing new foods with familiar texture level or pairing them with familiar tastes.

DALLAS — With obesity in children and adolescents growing at an alarming rate, patients seeking bariatric surgery are younger than ever, Dr. Scott A. Shikora said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

The incidence of severe obesity has doubled among children over the past 20 years. “Obese adults are producing obese children,” he said, noting that the problem has given rise to an epidemic of type 2 diabetes in children.

With obesity medications no more successful in children than in adults, there has been a dramatic increase in gastric bypass surgery in adolescents. According to Dr. Shikora, outcomes in adolescents are similar to those of adults: In adolescents who have gastric bypass, 75%–80% lose at least 50% of excess weight and successfully sustain weight loss over time with proper patient selection and follow-up. The surgery has been shown to improve health, prevent comorbidities and adult obesity, and improve self-esteem.

Retrospective studies indicate that the surgery can lower the risk of death an average of 33% in severely obese adolescents, with the largest reduction in mortality in cardiovascular deaths among obese diabetic adolescents.

Performing this procedure on children, however, raises safety and ethical questions; there are few studies on the safety and efficacy of gastric bypass in patients under age 18, and the maturity level of such patients brings up concerns about informed consent. The maturity and comprehension levels of young patients regarding nutritional compliance after surgery present a high risk for severe complications and long-term health problems, said Dr. Shikora of the bariatric surgery division at Tufts University, Boston.

Patients undergoing this procedure need lifelong nutritional supplementation to prevent osteoporosis, anemia, and other problems. He stressed the importance of a rigorous patient selection process and warned that gastric bypass surgery in this age group presents a much greater risk for lawsuits than does surgery in adults.

“It's one thing to be sued for medical complications of a 50-year-old,” he said, “but much more serious in a 16-year-old.”

Standards for adolescent surgical candidates should at least meet the American Society for Bariatric Surgery (ASBS) standard for adults, he said. He also suggested a social assessment by a behavioral therapist to determine if the patient is mature enough to comprehend the life changes that will be necessary after surgery and to determine parental involvement, to ensure that a good support system is in place.

The ASBS standard for selecting patients for gastric bypass surgery is 35 kg/m

He also offered alternative procedures physicians should consider.

Banding, which has been around for 30 years, can be effective for weight loss when the obesity is related to overeating because it creates a smaller stomach chamber without staples or rerouting. A new version of the procedure, called lap-band, uses an adjustable band that can be tightened or loosened to change the size of the stomach chamber and is easily removed.

This laparoscopic procedure may be a better choice for adolescents than gastric bypass, which carries a risk of life-threatening or long-term complications, Dr. Shikora said. But he noted, “This isn't perfect. The weight loss is not as good.”

A new implantable gastric stimulator device, or weight-loss pacemaker, could be an alternative to bariatric surgery if it is approved by the Food and Drug Administration. The device doesn't change the size of the stomach but instead creates a feeling of satiety, so the patient eats less. It is in use in Europe but is in clinical trials in the United States. The results so far are promising, with some patients reporting 100% loss of excess weight.

DALLAS — With obesity in children and adolescents growing at an alarming rate, patients seeking bariatric surgery are younger than ever, Dr. Scott A. Shikora said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

The incidence of severe obesity has doubled among children over the past 20 years. “Obese adults are producing obese children,” he said, noting that the problem has given rise to an epidemic of type 2 diabetes in children.

With obesity medications no more successful in children than in adults, there has been a dramatic increase in gastric bypass surgery in adolescents. According to Dr. Shikora, outcomes in adolescents are similar to those of adults: In adolescents who have gastric bypass, 75%–80% lose at least 50% of excess weight and successfully sustain weight loss over time with proper patient selection and follow-up. The surgery has been shown to improve health, prevent comorbidities and adult obesity, and improve self-esteem.

Retrospective studies indicate that the surgery can lower the risk of death an average of 33% in severely obese adolescents, with the largest reduction in mortality in cardiovascular deaths among obese diabetic adolescents.

Performing this procedure on children, however, raises safety and ethical questions; there are few studies on the safety and efficacy of gastric bypass in patients under age 18, and the maturity level of such patients brings up concerns about informed consent. The maturity and comprehension levels of young patients regarding nutritional compliance after surgery present a high risk for severe complications and long-term health problems, said Dr. Shikora of the bariatric surgery division at Tufts University, Boston.

Patients undergoing this procedure need lifelong nutritional supplementation to prevent osteoporosis, anemia, and other problems. He stressed the importance of a rigorous patient selection process and warned that gastric bypass surgery in this age group presents a much greater risk for lawsuits than does surgery in adults.

“It's one thing to be sued for medical complications of a 50-year-old,” he said, “but much more serious in a 16-year-old.”

Standards for adolescent surgical candidates should at least meet the American Society for Bariatric Surgery (ASBS) standard for adults, he said. He also suggested a social assessment by a behavioral therapist to determine if the patient is mature enough to comprehend the life changes that will be necessary after surgery and to determine parental involvement, to ensure that a good support system is in place.

The ASBS standard for selecting patients for gastric bypass surgery is 35 kg/m

He also offered alternative procedures physicians should consider.

Banding, which has been around for 30 years, can be effective for weight loss when the obesity is related to overeating because it creates a smaller stomach chamber without staples or rerouting. A new version of the procedure, called lap-band, uses an adjustable band that can be tightened or loosened to change the size of the stomach chamber and is easily removed.

This laparoscopic procedure may be a better choice for adolescents than gastric bypass, which carries a risk of life-threatening or long-term complications, Dr. Shikora said. But he noted, “This isn't perfect. The weight loss is not as good.”

A new implantable gastric stimulator device, or weight-loss pacemaker, could be an alternative to bariatric surgery if it is approved by the Food and Drug Administration. The device doesn't change the size of the stomach but instead creates a feeling of satiety, so the patient eats less. It is in use in Europe but is in clinical trials in the United States. The results so far are promising, with some patients reporting 100% loss of excess weight.

DALLAS — With obesity in children and adolescents growing at an alarming rate, patients seeking bariatric surgery are younger than ever, Dr. Scott A. Shikora said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

The incidence of severe obesity has doubled among children over the past 20 years. “Obese adults are producing obese children,” he said, noting that the problem has given rise to an epidemic of type 2 diabetes in children.

With obesity medications no more successful in children than in adults, there has been a dramatic increase in gastric bypass surgery in adolescents. According to Dr. Shikora, outcomes in adolescents are similar to those of adults: In adolescents who have gastric bypass, 75%–80% lose at least 50% of excess weight and successfully sustain weight loss over time with proper patient selection and follow-up. The surgery has been shown to improve health, prevent comorbidities and adult obesity, and improve self-esteem.

Retrospective studies indicate that the surgery can lower the risk of death an average of 33% in severely obese adolescents, with the largest reduction in mortality in cardiovascular deaths among obese diabetic adolescents.

Performing this procedure on children, however, raises safety and ethical questions; there are few studies on the safety and efficacy of gastric bypass in patients under age 18, and the maturity level of such patients brings up concerns about informed consent. The maturity and comprehension levels of young patients regarding nutritional compliance after surgery present a high risk for severe complications and long-term health problems, said Dr. Shikora of the bariatric surgery division at Tufts University, Boston.

Patients undergoing this procedure need lifelong nutritional supplementation to prevent osteoporosis, anemia, and other problems. He stressed the importance of a rigorous patient selection process and warned that gastric bypass surgery in this age group presents a much greater risk for lawsuits than does surgery in adults.

“It's one thing to be sued for medical complications of a 50-year-old,” he said, “but much more serious in a 16-year-old.”

Standards for adolescent surgical candidates should at least meet the American Society for Bariatric Surgery (ASBS) standard for adults, he said. He also suggested a social assessment by a behavioral therapist to determine if the patient is mature enough to comprehend the life changes that will be necessary after surgery and to determine parental involvement, to ensure that a good support system is in place.

The ASBS standard for selecting patients for gastric bypass surgery is 35 kg/m

He also offered alternative procedures physicians should consider.

Banding, which has been around for 30 years, can be effective for weight loss when the obesity is related to overeating because it creates a smaller stomach chamber without staples or rerouting. A new version of the procedure, called lap-band, uses an adjustable band that can be tightened or loosened to change the size of the stomach chamber and is easily removed.

This laparoscopic procedure may be a better choice for adolescents than gastric bypass, which carries a risk of life-threatening or long-term complications, Dr. Shikora said. But he noted, “This isn't perfect. The weight loss is not as good.”

A new implantable gastric stimulator device, or weight-loss pacemaker, could be an alternative to bariatric surgery if it is approved by the Food and Drug Administration. The device doesn't change the size of the stomach but instead creates a feeling of satiety, so the patient eats less. It is in use in Europe but is in clinical trials in the United States. The results so far are promising, with some patients reporting 100% loss of excess weight.

DALLAS — Early recognition of high-risk infants and excellent nutrition are the best treatments for osteopenia of prematurity, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient calcium and phosphorus accrual before birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

Left untreated, children can have fractures, rachitic changes, and shorter stature later in life, he said. Infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. The skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g and accrues exponentially until term.

Premature infants, therefore, should receive formula or breast milk fortified with calcium (200–230 mg/kg) per day, phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) to encourage normal bone growth. Fortified milk should be started when the infant tolerates 20–30 mL/kg per day of unfortified milk or breast milk. Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted. Calcium, phosphorus, and alkaline phosphatase should be measured every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Daily passive range of motion exercises increase bone mineral density Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of upper and lower extremities, taking care to avoid movements that could cause fracture or stress.

Osteopenia of prematurity is usually diagnosed using lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-rays to check for incidental fractures, or lucency of cortical bone, or bone density measurement with dual-energy x-ray absorptiometry or ultrasound.

Follow-up studies show low bone density persists until age 8–12 years; however, incidental fracture rates are no higher than for the rest of the population.

DALLAS — Early recognition of high-risk infants and excellent nutrition are the best treatments for osteopenia of prematurity, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient calcium and phosphorus accrual before birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

Left untreated, children can have fractures, rachitic changes, and shorter stature later in life, he said. Infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. The skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g and accrues exponentially until term.

Premature infants, therefore, should receive formula or breast milk fortified with calcium (200–230 mg/kg) per day, phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) to encourage normal bone growth. Fortified milk should be started when the infant tolerates 20–30 mL/kg per day of unfortified milk or breast milk. Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted. Calcium, phosphorus, and alkaline phosphatase should be measured every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Daily passive range of motion exercises increase bone mineral density Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of upper and lower extremities, taking care to avoid movements that could cause fracture or stress.

Osteopenia of prematurity is usually diagnosed using lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-rays to check for incidental fractures, or lucency of cortical bone, or bone density measurement with dual-energy x-ray absorptiometry or ultrasound.

Follow-up studies show low bone density persists until age 8–12 years; however, incidental fracture rates are no higher than for the rest of the population.

DALLAS — Early recognition of high-risk infants and excellent nutrition are the best treatments for osteopenia of prematurity, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient calcium and phosphorus accrual before birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

Left untreated, children can have fractures, rachitic changes, and shorter stature later in life, he said. Infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. The skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g and accrues exponentially until term.

Premature infants, therefore, should receive formula or breast milk fortified with calcium (200–230 mg/kg) per day, phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) to encourage normal bone growth. Fortified milk should be started when the infant tolerates 20–30 mL/kg per day of unfortified milk or breast milk. Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted. Calcium, phosphorus, and alkaline phosphatase should be measured every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Daily passive range of motion exercises increase bone mineral density Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of upper and lower extremities, taking care to avoid movements that could cause fracture or stress.

Osteopenia of prematurity is usually diagnosed using lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-rays to check for incidental fractures, or lucency of cortical bone, or bone density measurement with dual-energy x-ray absorptiometry or ultrasound.

Follow-up studies show low bone density persists until age 8–12 years; however, incidental fracture rates are no higher than for the rest of the population.

DALLAS — The best treatment for osteopenia of prematurity is prevention by early recognition of high-risk infants and making sure they get the best possible nutrition, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient accrual of calcium and phosphorus prior to birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

If left untreated, this disease can result in fractures, rachitic changes, and shorter stature later in life, he said.

Dr. McKay noted that infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. He explained that the skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g, and then accrues exponentially until term.

Premature infants, therefore, should be given formula or breast milk fortified with calcium (200–230 mg/kg per day), phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) for normal bone growth to occur. Fortified milk should be started when the infant is tolerating 20–30 mL/kg per day of unfortified milk or breast milk.

Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted, as well as measuring calcium, phosphorus, and alkaline phosphatase every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Recent studies indicate that daily passive range of motion exercises increase bone mineral density in preterm infants, Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of both upper and lower extremities, taking care to avoid movements that could cause fracture or stress to the infant.

Diagnosis of osteopenia of prematurity is usually made using both lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-ray to check for incidental fractures, or lucency of cortical bone, and/or bone density measurement with dual-energy x-ray absorptiometry or ultrasound. Additionally, Dr. McKay recommended monthly x-rays to look for incremental bone changes.

Findings from follow-up studies show that low bone density persists until at least age 8–12 years; however, the rate of incidental fractures is no higher than for the rest of population, Dr. McKay noted.

DALLAS — The best treatment for osteopenia of prematurity is prevention by early recognition of high-risk infants and making sure they get the best possible nutrition, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient accrual of calcium and phosphorus prior to birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

If left untreated, this disease can result in fractures, rachitic changes, and shorter stature later in life, he said.

Dr. McKay noted that infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. He explained that the skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g, and then accrues exponentially until term.

Premature infants, therefore, should be given formula or breast milk fortified with calcium (200–230 mg/kg per day), phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) for normal bone growth to occur. Fortified milk should be started when the infant is tolerating 20–30 mL/kg per day of unfortified milk or breast milk.

Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted, as well as measuring calcium, phosphorus, and alkaline phosphatase every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Recent studies indicate that daily passive range of motion exercises increase bone mineral density in preterm infants, Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of both upper and lower extremities, taking care to avoid movements that could cause fracture or stress to the infant.

Diagnosis of osteopenia of prematurity is usually made using both lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-ray to check for incidental fractures, or lucency of cortical bone, and/or bone density measurement with dual-energy x-ray absorptiometry or ultrasound. Additionally, Dr. McKay recommended monthly x-rays to look for incremental bone changes.

Findings from follow-up studies show that low bone density persists until at least age 8–12 years; however, the rate of incidental fractures is no higher than for the rest of population, Dr. McKay noted.

DALLAS — The best treatment for osteopenia of prematurity is prevention by early recognition of high-risk infants and making sure they get the best possible nutrition, Dr. Charles P. McKay said at a conference sponsored by the American Society for Parenteral and Enteral Nutrition.

Premature infants are at risk for osteopenia of prematurity, or neonatal rickets, due to insufficient accrual of calcium and phosphorus prior to birth, said Dr. McKay, director of the bone and mineral program at Alfred I. duPont Hospital for Children, Wilmington, Del.

If left untreated, this disease can result in fractures, rachitic changes, and shorter stature later in life, he said.

Dr. McKay noted that infants born prior to 28 weeks' gestation are at highest risk for osteopenia, which is usually diagnosed at age 2–4 months. He explained that the skeleton of at-term infants contains, on average, 25 g of calcium and 13 mg of phosphorus. Total bone calcium at 26 weeks' gestation, however, is just 5 g, and then accrues exponentially until term.

Premature infants, therefore, should be given formula or breast milk fortified with calcium (200–230 mg/kg per day), phosphorus (110–123 mg/kg per day), and vitamin D (400 mg/day) for normal bone growth to occur. Fortified milk should be started when the infant is tolerating 20–30 mL/kg per day of unfortified milk or breast milk.

Preterm infant formulas or fortified human milk should be continued until the infant is aged 6 months or the infant's growth rate is within the normal range, said Dr. McKay.

Length and weight should be followed carefully, he noted, as well as measuring calcium, phosphorus, and alkaline phosphatase every 1–4 weeks, depending on growth. “Be careful of ratios,” he warned. “The infant can develop hypercalcemia, or if [minerals are] out of balance, they won't be absorbed. If you see hypercalcemia in an infant, the first thing you should suspect is low phosphorus.”

Recent studies indicate that daily passive range of motion exercises increase bone mineral density in preterm infants, Dr. McKay noted, adding that he recommends extension, flexion, and range of motion exercises of both upper and lower extremities, taking care to avoid movements that could cause fracture or stress to the infant.

Diagnosis of osteopenia of prematurity is usually made using both lab results and radiologic tools. Low phosphate or high alkaline phosphatase is an indication of osteopenia. A radiologic diagnosis involves right forearm and chest x-ray to check for incidental fractures, or lucency of cortical bone, and/or bone density measurement with dual-energy x-ray absorptiometry or ultrasound. Additionally, Dr. McKay recommended monthly x-rays to look for incremental bone changes.

Findings from follow-up studies show that low bone density persists until at least age 8–12 years; however, the rate of incidental fractures is no higher than for the rest of population, Dr. McKay noted.

SAN ANTONIO — New prosthetic joint options for rheumatoid arthritis patients are a welcome alternative to conventional silicone implants for relieving pain and restoring function and stability, according to experts at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

New ball-and-joint prostheses relieve arthritic pain and restore articular and bony anatomy, providing more natural hand or forearm-wrist function and appearance and greater stability than provided by silicone implants, which break apart over time and may cause inflammation, said Dr. Richard A. Berger, a professor of orthopedics at the Mayo Clinic College of Medicine, Rochester, Minn., and consultant to Avanta Orthopaedics, San Diego.

Experience with silicone joint implants since their approval in the 1980s have shown that over time the implants tend to break apart, an outcome that can aggravate further inflammatory processes already underway in the joint, said Dr. Berger.

The newer implants promise both to remain structurally intact and to restore articular and bony anatomy, providing a more normal appearance to disfigured hands, said Dr. Robert D. Beckenbaugh, professor of orthopedics at the Mayo Clinic College of Medicine and consultant to Ascension Orthopedics Inc., Austin, Tex.

Dr. Berger noted that the Avanta uHead, replicating the distal ulnar head in the forearm, and the Scheker, a distal radioulnar joint (Aptis Medical, Louisville, Ky.), serve the same purpose but are used in patients with a different degree of problems. The uHead implant is a simple ball on a stem used to replace the end of the ulna when the patient has sufficient bone stock and soft tissue, he said. The Scheker ball-and-socket is used in patients with advanced degenerative rheumatoid disease because it connects directly to the ulnar rather than requiring bone stock or soft tissue to hold it in place.

The Avanta uHead joint is fabricated from a cobalt chrome-molybdenum alloy, and the stem is coated with titanium to promote osseointegration. Provided in right and left configurations and several sizes, the device stem is designed for snap-fit or can be cemented into the socket, which Dr. Berger noted improves the interface in rheumatoid disease patients with soft bone tissue, resulting in a more stable joint than without cement.

The Scheker prosthesis consists of a metal radial plate, socket, and ulna stem as well as an ultra-high-molecular-weight polyethylene ball for complete replacement of the joint, resulting in renewed range of motion that enables patients to use their hands for turning and lifting.

An initial clinical trial by Dr. Berger and Dr. William P. Cooney III, also a professor of orthopedics at Mayo Clinic College of Medicine, followed 26 patients with 28 ulnar head replacement arthroplasties for 30 months. Patients were an average of 51 years old, and all of them presented with pain, instability, or weakness or a combination of symptoms. Eighteen patients got “press-fit” implants, and 10 got cemented implants. At follow-up, 80% of patients were satisfied and reported no pain; 100% experienced improvement in symptoms, but 15% still had mild pain and one patient reported no pain relief. Postoperative pronation and supination of the forearm were 75 degrees and 70 degrees, respectively, and grip strength improved by 10%. There were two acute complications—an ulna shaft nondisplaced split fracture during impaction of the device and an acute dorsal sensory ulnar nerve neuropraxia—and four chronic complications: a neuroma, two cases of residual instability, and one case of implant loosening, all of which required revision surgery. The Mayo Clinic wrist score was used to assess outcomes, which were excellent in 4 patients, good in 18, and poor in 6.

Other options for treatment of hands disabled by arthritis or trauma are pyrocarbon implants for the proximal interphalangeal (PIP), trapeziometacarpal, and metacarpophalangeal (MCP) joints. Both the PIP pyrocarbon total joint and the MCP pyrocarbon total joint prostheses (Ascension Orthopedics) are made from a low-friction pyrolytic carbon-coated graphite substrate compound that has low wear properties and is biologically compatible with bone tissue, said Dr. Beckenbaugh.

The pyrocarbon PIP joint is a bicondylar, semiconstrained prosthesis for total joint replacement with anatomically shaped stems that press-fit into the intramedullary canal to achieve fixation by direct implant-to-bone apposition. The distal component has a bicupped design that allows slight sliding of the proximal condylar component and dorsal extensor to resist subluxation. Distal and proximal components come in four sizes, which can be matched with smaller or larger opposites to best fit the medullary canal of the patient's proximal and middle phalanx.

The pyrocarbon MCP joint replacement builds on pyrolytic carbon arthroplasty technology developed in 1977 but abandoned 10 years later for lack of funding. The new device uses the original MCP implant's simple ball-and-socket design, which had demonstrated very satisfactory results. A few modifications have been made; for example, the stems were enlarged and shaped to be a better physiologic fit with the medullary canal than the original design, the dorsal surface of the joint design was extended 10% to increase stability against volar subluxation, and the pyrolytic carbon material was strengthened through an improved manufacturing process.

Dr. Beckenbaugh pointed out that the success of ball-and-socket implants requires the capability to construct a stable soft tissue envelope to allow bony fixation by appositional bone growth. While these implants may be ideal for osteoarthritis, posttraumatic arthritis, and some rheumatoid patients, the old silicone or cemented implants may be preferred for rheumatoid patients with soft medullary tissue and thin cortical bone.

He said that the greatest potential problem with ball-and-socket design is subluxation and/or recurrent ulnar deviation, which can be prevented with careful surgical technique and postoperative care. The new devices require a longer postoperative immobilization (usually 3–4 weeks), compared with silicone arthroplasty, to allow soft tissue to heal and create stability before motion therapy is begun.

All of the protheses discussed by Dr. Berger and Dr. Beckenbaugh have received approval from the Food and Drug Administration for use in the United States and the CE Mark for approval in Europe.

Hand disabled by rheumatoid arthritis before use of PIP Pyrocarbon Implants.

Surgical placement of the PIP Pyrocarbon Implants enable hand flexion in same patient. Photos courtesy Dr. Robert D. Beckenbaugh

SAN ANTONIO — New prosthetic joint options for rheumatoid arthritis patients are a welcome alternative to conventional silicone implants for relieving pain and restoring function and stability, according to experts at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

New ball-and-joint prostheses relieve arthritic pain and restore articular and bony anatomy, providing more natural hand or forearm-wrist function and appearance and greater stability than provided by silicone implants, which break apart over time and may cause inflammation, said Dr. Richard A. Berger, a professor of orthopedics at the Mayo Clinic College of Medicine, Rochester, Minn., and consultant to Avanta Orthopaedics, San Diego.

Experience with silicone joint implants since their approval in the 1980s have shown that over time the implants tend to break apart, an outcome that can aggravate further inflammatory processes already underway in the joint, said Dr. Berger.

The newer implants promise both to remain structurally intact and to restore articular and bony anatomy, providing a more normal appearance to disfigured hands, said Dr. Robert D. Beckenbaugh, professor of orthopedics at the Mayo Clinic College of Medicine and consultant to Ascension Orthopedics Inc., Austin, Tex.

Dr. Berger noted that the Avanta uHead, replicating the distal ulnar head in the forearm, and the Scheker, a distal radioulnar joint (Aptis Medical, Louisville, Ky.), serve the same purpose but are used in patients with a different degree of problems. The uHead implant is a simple ball on a stem used to replace the end of the ulna when the patient has sufficient bone stock and soft tissue, he said. The Scheker ball-and-socket is used in patients with advanced degenerative rheumatoid disease because it connects directly to the ulnar rather than requiring bone stock or soft tissue to hold it in place.

The Avanta uHead joint is fabricated from a cobalt chrome-molybdenum alloy, and the stem is coated with titanium to promote osseointegration. Provided in right and left configurations and several sizes, the device stem is designed for snap-fit or can be cemented into the socket, which Dr. Berger noted improves the interface in rheumatoid disease patients with soft bone tissue, resulting in a more stable joint than without cement.

The Scheker prosthesis consists of a metal radial plate, socket, and ulna stem as well as an ultra-high-molecular-weight polyethylene ball for complete replacement of the joint, resulting in renewed range of motion that enables patients to use their hands for turning and lifting.

An initial clinical trial by Dr. Berger and Dr. William P. Cooney III, also a professor of orthopedics at Mayo Clinic College of Medicine, followed 26 patients with 28 ulnar head replacement arthroplasties for 30 months. Patients were an average of 51 years old, and all of them presented with pain, instability, or weakness or a combination of symptoms. Eighteen patients got “press-fit” implants, and 10 got cemented implants. At follow-up, 80% of patients were satisfied and reported no pain; 100% experienced improvement in symptoms, but 15% still had mild pain and one patient reported no pain relief. Postoperative pronation and supination of the forearm were 75 degrees and 70 degrees, respectively, and grip strength improved by 10%. There were two acute complications—an ulna shaft nondisplaced split fracture during impaction of the device and an acute dorsal sensory ulnar nerve neuropraxia—and four chronic complications: a neuroma, two cases of residual instability, and one case of implant loosening, all of which required revision surgery. The Mayo Clinic wrist score was used to assess outcomes, which were excellent in 4 patients, good in 18, and poor in 6.

Other options for treatment of hands disabled by arthritis or trauma are pyrocarbon implants for the proximal interphalangeal (PIP), trapeziometacarpal, and metacarpophalangeal (MCP) joints. Both the PIP pyrocarbon total joint and the MCP pyrocarbon total joint prostheses (Ascension Orthopedics) are made from a low-friction pyrolytic carbon-coated graphite substrate compound that has low wear properties and is biologically compatible with bone tissue, said Dr. Beckenbaugh.

The pyrocarbon PIP joint is a bicondylar, semiconstrained prosthesis for total joint replacement with anatomically shaped stems that press-fit into the intramedullary canal to achieve fixation by direct implant-to-bone apposition. The distal component has a bicupped design that allows slight sliding of the proximal condylar component and dorsal extensor to resist subluxation. Distal and proximal components come in four sizes, which can be matched with smaller or larger opposites to best fit the medullary canal of the patient's proximal and middle phalanx.

The pyrocarbon MCP joint replacement builds on pyrolytic carbon arthroplasty technology developed in 1977 but abandoned 10 years later for lack of funding. The new device uses the original MCP implant's simple ball-and-socket design, which had demonstrated very satisfactory results. A few modifications have been made; for example, the stems were enlarged and shaped to be a better physiologic fit with the medullary canal than the original design, the dorsal surface of the joint design was extended 10% to increase stability against volar subluxation, and the pyrolytic carbon material was strengthened through an improved manufacturing process.

Dr. Beckenbaugh pointed out that the success of ball-and-socket implants requires the capability to construct a stable soft tissue envelope to allow bony fixation by appositional bone growth. While these implants may be ideal for osteoarthritis, posttraumatic arthritis, and some rheumatoid patients, the old silicone or cemented implants may be preferred for rheumatoid patients with soft medullary tissue and thin cortical bone.

He said that the greatest potential problem with ball-and-socket design is subluxation and/or recurrent ulnar deviation, which can be prevented with careful surgical technique and postoperative care. The new devices require a longer postoperative immobilization (usually 3–4 weeks), compared with silicone arthroplasty, to allow soft tissue to heal and create stability before motion therapy is begun.

All of the protheses discussed by Dr. Berger and Dr. Beckenbaugh have received approval from the Food and Drug Administration for use in the United States and the CE Mark for approval in Europe.

Hand disabled by rheumatoid arthritis before use of PIP Pyrocarbon Implants.

Surgical placement of the PIP Pyrocarbon Implants enable hand flexion in same patient. Photos courtesy Dr. Robert D. Beckenbaugh

SAN ANTONIO — New prosthetic joint options for rheumatoid arthritis patients are a welcome alternative to conventional silicone implants for relieving pain and restoring function and stability, according to experts at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

New ball-and-joint prostheses relieve arthritic pain and restore articular and bony anatomy, providing more natural hand or forearm-wrist function and appearance and greater stability than provided by silicone implants, which break apart over time and may cause inflammation, said Dr. Richard A. Berger, a professor of orthopedics at the Mayo Clinic College of Medicine, Rochester, Minn., and consultant to Avanta Orthopaedics, San Diego.

Experience with silicone joint implants since their approval in the 1980s have shown that over time the implants tend to break apart, an outcome that can aggravate further inflammatory processes already underway in the joint, said Dr. Berger.

The newer implants promise both to remain structurally intact and to restore articular and bony anatomy, providing a more normal appearance to disfigured hands, said Dr. Robert D. Beckenbaugh, professor of orthopedics at the Mayo Clinic College of Medicine and consultant to Ascension Orthopedics Inc., Austin, Tex.

Dr. Berger noted that the Avanta uHead, replicating the distal ulnar head in the forearm, and the Scheker, a distal radioulnar joint (Aptis Medical, Louisville, Ky.), serve the same purpose but are used in patients with a different degree of problems. The uHead implant is a simple ball on a stem used to replace the end of the ulna when the patient has sufficient bone stock and soft tissue, he said. The Scheker ball-and-socket is used in patients with advanced degenerative rheumatoid disease because it connects directly to the ulnar rather than requiring bone stock or soft tissue to hold it in place.

The Avanta uHead joint is fabricated from a cobalt chrome-molybdenum alloy, and the stem is coated with titanium to promote osseointegration. Provided in right and left configurations and several sizes, the device stem is designed for snap-fit or can be cemented into the socket, which Dr. Berger noted improves the interface in rheumatoid disease patients with soft bone tissue, resulting in a more stable joint than without cement.

The Scheker prosthesis consists of a metal radial plate, socket, and ulna stem as well as an ultra-high-molecular-weight polyethylene ball for complete replacement of the joint, resulting in renewed range of motion that enables patients to use their hands for turning and lifting.

An initial clinical trial by Dr. Berger and Dr. William P. Cooney III, also a professor of orthopedics at Mayo Clinic College of Medicine, followed 26 patients with 28 ulnar head replacement arthroplasties for 30 months. Patients were an average of 51 years old, and all of them presented with pain, instability, or weakness or a combination of symptoms. Eighteen patients got “press-fit” implants, and 10 got cemented implants. At follow-up, 80% of patients were satisfied and reported no pain; 100% experienced improvement in symptoms, but 15% still had mild pain and one patient reported no pain relief. Postoperative pronation and supination of the forearm were 75 degrees and 70 degrees, respectively, and grip strength improved by 10%. There were two acute complications—an ulna shaft nondisplaced split fracture during impaction of the device and an acute dorsal sensory ulnar nerve neuropraxia—and four chronic complications: a neuroma, two cases of residual instability, and one case of implant loosening, all of which required revision surgery. The Mayo Clinic wrist score was used to assess outcomes, which were excellent in 4 patients, good in 18, and poor in 6.

Other options for treatment of hands disabled by arthritis or trauma are pyrocarbon implants for the proximal interphalangeal (PIP), trapeziometacarpal, and metacarpophalangeal (MCP) joints. Both the PIP pyrocarbon total joint and the MCP pyrocarbon total joint prostheses (Ascension Orthopedics) are made from a low-friction pyrolytic carbon-coated graphite substrate compound that has low wear properties and is biologically compatible with bone tissue, said Dr. Beckenbaugh.

The pyrocarbon PIP joint is a bicondylar, semiconstrained prosthesis for total joint replacement with anatomically shaped stems that press-fit into the intramedullary canal to achieve fixation by direct implant-to-bone apposition. The distal component has a bicupped design that allows slight sliding of the proximal condylar component and dorsal extensor to resist subluxation. Distal and proximal components come in four sizes, which can be matched with smaller or larger opposites to best fit the medullary canal of the patient's proximal and middle phalanx.

The pyrocarbon MCP joint replacement builds on pyrolytic carbon arthroplasty technology developed in 1977 but abandoned 10 years later for lack of funding. The new device uses the original MCP implant's simple ball-and-socket design, which had demonstrated very satisfactory results. A few modifications have been made; for example, the stems were enlarged and shaped to be a better physiologic fit with the medullary canal than the original design, the dorsal surface of the joint design was extended 10% to increase stability against volar subluxation, and the pyrolytic carbon material was strengthened through an improved manufacturing process.

Dr. Beckenbaugh pointed out that the success of ball-and-socket implants requires the capability to construct a stable soft tissue envelope to allow bony fixation by appositional bone growth. While these implants may be ideal for osteoarthritis, posttraumatic arthritis, and some rheumatoid patients, the old silicone or cemented implants may be preferred for rheumatoid patients with soft medullary tissue and thin cortical bone.

He said that the greatest potential problem with ball-and-socket design is subluxation and/or recurrent ulnar deviation, which can be prevented with careful surgical technique and postoperative care. The new devices require a longer postoperative immobilization (usually 3–4 weeks), compared with silicone arthroplasty, to allow soft tissue to heal and create stability before motion therapy is begun.

All of the protheses discussed by Dr. Berger and Dr. Beckenbaugh have received approval from the Food and Drug Administration for use in the United States and the CE Mark for approval in Europe.

Hand disabled by rheumatoid arthritis before use of PIP Pyrocarbon Implants.

Surgical placement of the PIP Pyrocarbon Implants enable hand flexion in same patient. Photos courtesy Dr. Robert D. Beckenbaugh